Editing Management of Care

'''Management of Care''' is the body of nursing knowledge concerned with directing, coordinating, and safeguarding the delivery of patient care. It is the largest content area on the NCLEX-RN and appears as Coordinated Care on the NCLEX-PN (National Council of State Boards of Nursing [NCSBN], 2026a, 2026b). This article is the shared core content for both tracks. Track-specific practice questions and flashcards are linked from [[:Category:Management of Care]].

A note on how to read this article: nearly every rule below has a state-level exception, because nursing scope of practice is defined by each state's nurse practice act, not by federal law or by any textbook. Licensure examinations test the nationally common denominator. Actual practice is governed by the nurse practice act of the state where the nurse is licensed, the facility's policies, and the individual nurse's demonstrated competence. Where those three conflict, the most restrictive one controls.

== Scope of Practice ==

Scope of practice defines what a given license permits a person to do. It is established by each state's nurse practice act and interpreted by that state's board of nursing. Facility policy may narrow a scope but can never widen it, and a provider's order can never authorize a nurse to perform an act outside the nurse's legal scope.

=== The three roles tested on licensure examinations ===

'''Registered nurse (RN).''' The RN is accountable for the full nursing process: the initial and ongoing comprehensive '''assessment''', nursing '''diagnosis''', development and revision of the '''plan of care''', initial patient and family '''teaching''', and '''evaluation''' of whether interventions worked. The RN is also accountable for the delegation decision itself and for supervising those to whom care is delegated. The RN cares for the unstable, the newly admitted, and the unpredictable. Tasks commonly reserved for the RN on examinations include intravenous push medications, blood product administration, initiation and titration of vasoactive drips, total parenteral nutrition, care planning, triage, and the admission assessment.

'''Licensed practical or vocational nurse (LPN/LVN).''' The LPN is a licensed nurse who practices under the direction of an RN or an authorized provider. The LPN '''collects data''' and contributes focused observations to the assessment the RN owns; the LPN does not perform the initial comprehensive assessment. The LPN '''reinforces''' teaching the RN has already initiated; the LPN does not perform initial teaching. The LPN cares for '''stable patients with predictable outcomes'''. Skills commonly within LPN scope include administering most oral, topical, subcutaneous, and intramuscular medications, sterile dressing changes and complex wound care, urinary catheterization, nasogastric tube feeding and maintenance, tracheostomy care and suctioning, ostomy care, capillary blood glucose testing, and monitoring patients who have already been stabilized.

'''Assistive personnel (AP/UAP/CNA).''' Assistive personnel are unlicensed. They may perform '''standard, unvarying tasks on stable patients that require no nursing judgment''': hygiene and bathing, feeding a patient with no swallowing impairment, oral care, ambulation and transfers, positioning and turning, routine range of motion, bed making, measuring and recording vital signs on a stable patient, intake and output, weights, specimen collection, and stocking. Assistive personnel may report findings but may not interpret them.

=== The three verbs that are never delegated ===

A dependable examination heuristic is that the RN never delegates '''assessment, teaching, evaluation, or nursing judgment''' to anyone, and never delegates the care of an '''unstable''' patient. If a question stem contains "assess," "teach," "evaluate," "plan," or describes a patient whose condition is changing, the answer is the RN. If the stem describes a routine, predictable task on a stable patient, an LPN or assistive personnel may be correct.

'''Application note.''' Students lose points by reasoning about who is physically capable of a task rather than who is legally accountable for it. An experienced assistive personnel may be far better at obtaining a blood pressure than a new graduate RN, and that is irrelevant. The question is who is accountable for deciding what the blood pressure means.

== The Five Rights of Delegation ==

Delegation is the transfer of authority to perform a selected nursing task in a selected situation to a competent individual, while the delegating nurse retains accountability for the outcome (NCSBN & American Nurses Association [ANA], 2019). The delegatee is responsible for the task performed. The delegator remains accountable for the decision to delegate and for the supervision that follows. Accountability is never transferred.

=== 1. Right Task ===
The task must be one that is legally delegable, that recurs frequently in daily care, that is standardized and unvarying, that has a predictable outcome, that carries minimal risk, and that requires no independent nursing judgment. Ask: is this task within my own scope to begin with, and does my state and my facility permit it to be delegated to this category of worker?

=== 2. Right Circumstance ===
The patient must be '''stable''' with a '''predictable''' outcome, the setting must be appropriate, and the necessary equipment and resources must be available. The same task may be delegable for one patient and not for another. Ambulating a patient two days post-hip arthroplasty who walked well yesterday is a reasonable delegation. Ambulating that same patient for the first time after an episode of orthostatic hypotension is not.

=== 3. Right Person ===
The right person, delegating the right task, to the right patient. This requires that the nurse know the delegatee's job description, the delegatee's demonstrated competence, and the delegatee's current workload. "She has a certificate" is not the same as "I have verified she can do this."

=== 4. Right Direction and Communication ===
The delegation must be clear, concise, correct, and complete. It should state the specific task, the expected outcome, any limits, the time frame, and precisely '''what to report back and when'''. Vague delegation is the most common failure point. "Keep an eye on him" is not a delegation. "Take his blood pressure and heart rate every hour and tell me immediately if the systolic is below 100 or the heart rate is above 110" is a delegation.

=== 5. Right Supervision and Evaluation ===
The nurse monitors performance, is available for questions, intervenes when needed, gives feedback, and evaluates both the patient outcome and the delegation process. Supervision is not optional and it is not satisfied by being on the same unit. For a new employee or a high-risk task, supervision means direct observation.

'''Application note.''' When a delegated task goes wrong, examination items and real-world review both ask the same question: was the task appropriate, was the person competent, was the direction complete, and was supervision provided? If the nurse cannot answer yes to all four, the accountability sits with the nurse.

=== Delegation versus assignment ===
'''Assignment''' distributes work that is already within the receiving person's scope and job description, such as giving an LPN a group of stable medical patients. '''Delegation''' transfers authority for a task the delegatee would not otherwise be authorized to perform on their own. In practice on licensure examinations the two are tested with the same five-rights reasoning, but the distinction explains why an RN "assigns" patients to an LPN and "delegates" a task to assistive personnel.

=== Making an assignment ===
When distributing a group of patients among staff, the RN considers acuity and complexity, the stability and predictability of each patient, the skill and experience of each staff member, geographic clustering to reduce travel, continuity with prior shifts, and infection-control and isolation needs. The '''most complex, least stable, or newly admitted''' patients go to the RN. Float nurses and travelers receive the '''most stable''' and least specialized patients, because their orientation to the unit is limited. A pregnant staff member should not be assigned to a patient receiving internal radiation implants or with certain communicable exposures.

== Establishing Priorities ==

Prioritization determines which patient is seen first and which problem is addressed first. Several frameworks are applied in sequence; they rarely conflict, and when they do, the physiologic frameworks win.

=== Airway, breathing, circulation ===
'''ABC''' is the first filter. An airway problem outranks a breathing problem, which outranks a circulation problem, which outranks everything else. Signs pointing to airway compromise, such as stridor, drooling, gurgling, a swelling tongue, or the inability to speak, take absolute precedence.

'''An important qualifier.''' Cardiopulmonary resuscitation for a pulseless patient uses '''C-A-B''' (compressions first), because the emergency is circulatory arrest, not obstruction. ABC is the framework for prioritizing among patients; CAB is the sequence within a cardiac arrest.

=== Maslow's hierarchy of needs ===
When no patient has an ABC problem, physiologic needs (oxygen, fluid, nutrition, elimination, pain, rest) outrank safety and security needs, which outrank love and belonging, which outrank esteem, which outrank self-actualization. This framework separates a physical need from a psychosocial one. The practical caution is that Maslow is applied '''after''' ABC and safety, not instead of them, and a psychosocial answer can still be correct when every option is psychosocial or when the physiologic issue has already been addressed.

=== Acute versus chronic, unstable versus stable ===
An '''acute''' problem outranks a '''chronic''' one. An '''unstable''' patient outranks a stable one. A '''sudden, unexpected''' change outranks a gradual, expected one. A patient whose findings are '''inconsistent with the diagnosis''' outranks a patient whose findings are exactly what the diagnosis predicts. A patient with chronic 8-out-of-10 arthritis pain waits behind the postoperative patient whose pain suddenly changed in character.

=== Actual versus potential, and risk of harm ===
An '''actual''' problem outranks a '''risk''' or potential problem. Among risks, the one with the highest probability of serious, irreversible harm comes first.

=== The nursing process as a priority framework ===
Assessment precedes intervention. When the options include both assessing and acting, assess first, '''unless''' the situation is an immediate life threat with an obvious remedy. If a ventilator alarms and the patient is cyanotic, do not gather more data; disconnect and manually ventilate. If a patient reports dizziness, assess before acting.

=== Safety and the least restrictive intervention ===
Physical safety concerns, including fall risk, wrong-patient errors, and infection transmission, are prioritized above comfort and psychosocial needs. When several safety interventions would work, choose the '''least restrictive''' one that is effective.

=== Triage frameworks ===
In an emergency department, patients are sorted by acuity so that the sickest are seen first. In a '''mass casualty or disaster''', the goal changes from doing the most for each individual to doing the '''greatest good for the greatest number'''. Under a color-coded disaster system, red or immediate marks life-threatening injuries that are survivable with rapid intervention; yellow or delayed marks serious injuries that can tolerate a short wait; green or minimal marks the walking wounded; and black or expectant marks injuries incompatible with survival given available resources. Recognizing this reversal is the point of most disaster items: in daily practice the most critically injured are treated first, and in a disaster the patient who cannot be saved with the resources at hand is not treated first.

'''Application note.''' A practical sequence for any "which patient do you see first" item is: eliminate any option that is an expected finding for that diagnosis, then apply ABC, then unstable over stable, then acute over chronic, then actual over potential. If two options remain, ask which patient will deteriorate soonest without you.

== Continuity of Care ==

Continuity of care is the coordinated, uninterrupted delivery of care as a patient moves across shifts, units, facilities, and levels of care. Most breakdowns occur at transitions.

=== Handoff communication ===
Handoff is the transfer of both information and responsibility. It should be a structured, interactive, face-to-face or synchronous exchange with an opportunity to ask questions, ideally with limited interruptions, and it should include the opportunity to review relevant data together. Inadequate handoff is a persistent contributor to sentinel events (The Joint Commission, 2017).

'''SBAR''' is the most widely tested structure (Haig et al., 2006):
* '''S'''ituation: who the patient is and what is happening right now.
* '''B'''ackground: the relevant clinical context, diagnosis, and history.
* '''A'''ssessment: what the nurse thinks the problem is.
* '''R'''ecommendation: what the nurse is asking the recipient to do.

A frequent examination point is that the '''R''' is not optional. A nurse who reports abnormal data without stating what is needed has not completed the communication.

'''Read-back.''' Verbal and telephone orders and critical laboratory values must be written down and '''read back''' to the sender for verification. Verbal orders should be reserved for emergencies and situations where the provider cannot access the record, and they must be authenticated by the provider within the time frame set by policy.

=== Transfer, discharge, and referral ===
'''Discharge planning begins on admission.''' It is interdisciplinary, and it is based on the patient's expected level of function, support system, home environment, finances, and health literacy. A transfer to another unit or facility requires a report to the receiving nurse, transfer of the record and medication list, and provider orders for the new setting.

'''Referrals''' connect the patient to resources outside the nurse's scope. Common referral targets tested on examinations include physical, occupational, and speech therapy; the registered dietitian for nutrition needs including swallowing-safe diets; the social worker for financial, housing, placement, and psychosocial resources; the case manager for coordination and utilization; respiratory therapy; the wound and ostomy nurse; the chaplain for spiritual needs; home health; and hospice. In most systems the RN may initiate a referral, while an order may be required for the service to be reimbursed.

'''Medication reconciliation''' occurs at admission, at every transfer between levels of care, and at discharge. It compares what the patient was actually taking, including over-the-counter drugs, herbals, and supplements, against what is ordered now.

=== Case management ===
The case manager coordinates care across the continuum for a defined population, monitors resource use and length of stay, arranges services, and works to prevent readmission. Case management is a coordinating role, not a bedside care role, and the case manager does not replace the bedside nurse's accountability.

=== Confidentiality and information security ===
Protected health information may be disclosed only to those with a legitimate need to know for treatment, payment, or health care operations, and only the '''minimum necessary''' for the purpose (Health Insurance Portability and Accountability Act of 1996). Practical rules that appear on examinations: do not discuss patients in elevators, hallways, or cafeterias; do not access the record of a patient not in your care, including a coworker, a family member, or yourself in many facilities; log off shared workstations; position screens away from public view; verify the identity and authorization of any caller before releasing information; and do not post anything about a patient on social media, including images that seem de-identified. A nurse may share information with another member of the treatment team caring for that patient. A nurse may not share it with a family member simply because the family member asks, absent the patient's authorization.

== Informed Consent ==

Informed consent is a process, not a signature. It rests on the ethical principle of autonomy and on the legal principle that touching a competent adult without permission is battery.

=== Elements ===
Valid informed consent requires that the patient receives a description of the '''procedure''', its '''risks''' and '''benefits''', reasonable '''alternatives''' including doing nothing, the '''consequences of refusal''', and who will perform it; that the patient is '''competent''' and of legal age; and that consent is given '''voluntarily''' and free of coercion.

=== Who does what ===
'''The provider performing the procedure''' is legally responsible for disclosing the information and obtaining consent. '''The nurse's role''' is to witness the signature, to verify that the signature is voluntary and that the patient is competent to sign, and to confirm that the patient understands what was explained. The nurse also serves as the patient's advocate.

'''The single most tested point in this section:''' if the patient expresses confusion, cannot describe the procedure, or asks a question about risks or alternatives, the nurse '''stops the process and notifies the provider''' to return and complete the disclosure. The nurse does not explain the procedure to fill the gap, and does not have the patient sign and sort it out later.

=== Consent for those who cannot consent ===
* '''Minors''' generally require a parent or legal guardian. Exceptions vary by state and commonly include '''emancipated minors''' (married, in military service, or court-declared) and minors seeking care for pregnancy, sexually transmitted infection, substance use, or mental health.
* '''Emergencies''' involving an immediate threat to life or limb, when the patient cannot consent and no surrogate is reachable, proceed under '''implied consent'''.
* '''Adults who lack decision-making capacity''' are represented by a health care proxy or durable power of attorney for health care if one exists, and otherwise by a legally recognized surrogate in the order set by state law.
* '''Language barriers''' require a '''qualified medical interpreter'''. Family members, especially minor children, should not interpret for consent.

'''A competent adult may refuse any treatment, including life-sustaining treatment, for any reason or no reason.''' The nurse documents the refusal, ensures the patient understood the consequences, notifies the provider, and does not treat over the refusal.

== Advance Directives ==

Advance directives are documents by which a person states health care preferences in advance or names a decision maker, to be used if the person later loses capacity.

* '''Living will:''' a written statement of which treatments the person does or does not want, typically in terminal or permanently unconscious states.
* '''Durable power of attorney for health care / health care proxy:''' names a person to make decisions when the patient cannot. This is generally the more flexible and more useful document, because a named person can respond to situations the living will did not anticipate.
* '''POLST or MOLST:''' a portable '''medical order''' set signed by a provider that translates goals into actionable orders across settings. Unlike a living will, it is an order and is followed immediately.
* '''Do-not-resuscitate (DNR) / allow natural death order:''' a provider order that cardiopulmonary resuscitation is not to be performed. It applies to resuscitation only.

The '''Patient Self-Determination Act of 1990''' requires facilities receiving Medicare or Medicaid funds to ask on admission whether the patient has an advance directive, to provide written information about the right to make one, to document its existence in the record, and not to discriminate based on whether one exists. Facilities may not require an advance directive as a condition of care.

'''Application notes.'''
* A DNR order is '''not''' an order to withhold care. Patients with DNR orders still receive pain control, oxygen, antibiotics, nutrition, positioning, suctioning, wound care, and every other indicated treatment unless separately limited. Confusing DNR with "do not treat" is a recurring examination distractor and a real source of harm.
* An advance directive '''only takes effect when the patient loses decision-making capacity'''. A conscious, competent patient's current expressed wish always overrides the document, and the patient may revoke or change the directive at any time, verbally or in writing.
* If a family member demands care that contradicts a valid directive, the nurse notifies the provider and, as needed, the ethics committee. The nurse does not simply comply with the louder voice.

== Legal Principles in Nursing ==

=== Sources of law that govern nursing ===
'''Statutory law''' includes the state nurse practice act. '''Regulatory or administrative law''' includes board of nursing rules and agency regulations. '''Common law''' is developed through court decisions. '''Criminal law''' addresses offenses against the state and includes acts such as diverting controlled substances or falsifying records. '''Civil law''' addresses wrongs between parties and is where most nursing liability lives.

=== Negligence and malpractice ===
'''Negligence''' is the failure to act as a reasonably prudent person would act under similar circumstances. It can be committed by anyone. '''Malpractice''' is professional negligence: the failure of a licensed professional to meet the standard of care of a reasonably prudent nurse with similar education and experience in similar circumstances.

Proving malpractice requires all of the following elements. If any one fails, the claim fails:
# '''Duty:''' a nurse-patient relationship existed, creating an obligation to provide care.
# '''Breach of duty:''' the nurse's action or omission fell below the standard of care.
# '''Causation:''' the breach directly caused the injury (proximate cause).
# '''Damages:''' actual harm resulted, whether physical, emotional, or financial.

Common allegations against nurses include medication errors, failure to assess and monitor, '''failure to rescue''' (recognizing deterioration but not escalating it), failure to follow the chain of command, patient falls, failure to use equipment safely, documentation failures, and failure to communicate a change in status to the provider.

=== Intentional torts ===
* '''Assault:''' a threat that creates a reasonable fear of harmful contact. No touching is required. Telling a patient he will be held down for an injection is assault.
* '''Battery:''' harmful or offensive contact without consent. Giving that injection over the patient's refusal is battery.
* '''False imprisonment:''' unlawfully confining a patient, including improper use of restraints or preventing a competent adult from leaving against medical advice.
* '''Invasion of privacy:''' unauthorized disclosure of patient information or exposure of the patient's body.
* '''Defamation:''' a false statement that damages reputation. '''Slander''' is spoken, '''libel''' is written.
* '''Fraud:''' willful misrepresentation, such as falsifying a record or misrepresenting credentials.

=== Restraints ===
Restraints are a last resort. Less restrictive alternatives must be tried and documented first: reorientation, bed and chair alarms, moving the patient nearer the nurses' station, involving family, toileting schedules, addressing pain, hunger, and delirium triggers, and removing lines and tubes when no longer needed.

Rules that appear repeatedly on examinations:
* A '''provider order is required'''. In an emergency an RN may initiate restraint and must obtain the order promptly per policy.
* '''PRN or standing orders for restraints are prohibited.'''
* Orders for restraint of '''violent or self-destructive''' behavior are time-limited and must be renewed within maximum intervals: 4 hours for adults 18 and older, 2 hours for ages 9 through 17, and 1 hour for children under 9 (Centers for Medicare & Medicaid Services [CMS], 2020).
* A '''face-to-face evaluation''' of the patient is required within 1 hour of initiating restraint for violent or self-destructive behavior.
* Use the '''least restrictive''' effective device, apply it so it can be released quickly, secure ties to the '''movable part of the bed frame''', never to the side rail, and use a '''quick-release knot'''.
* Monitor circulation, sensation, and skin integrity; release and provide range of motion, repositioning, toileting, and fluids per policy, commonly every 2 hours.
* Assessment, alternatives attempted, patient response, and continued need must be documented.

=== Documentation ===
The record is a clinical, legal, and billing document. Entries must be factual, objective, accurate, complete, timely, and legible, and must identify the author. Chart what was observed, what was done, and how the patient responded, not conclusions or opinions about other staff. Never chart in advance. Never chart for another person. Correct an error by drawing a single line through it, writing the correction with date, time, and initials, and leaving the original readable. Never erase, white out, or delete.

'''Incident or occurrence reports''' are internal quality and risk-management tools. The event itself and the patient's condition and treatment are documented in the medical record, but the record should '''not''' state that an incident report was completed, and the report is not filed in the chart.

=== Mandatory reporting and protective statutes ===
Nurses are '''mandatory reporters''' of suspected child abuse, elder and dependent-adult abuse, and certain communicable diseases and injuries such as gunshot and stab wounds, with specifics set by state law. Reporting requires '''reasonable suspicion''', not proof, and good-faith reporters are protected from liability. '''Good Samaritan laws''' protect a nurse who volunteers aid at the scene of an emergency, provided the nurse acts within the scope of ordinary skill, does not accept payment, and does not abandon the person once care is begun.

=== Chain of command ===
The chain of command is the formal route for escalating unresolved patient safety concerns. A representative nursing chain runs from assistive personnel to the LPN, to the RN, to the charge nurse, to the nurse manager, to the house supervisor or director, to the chief nursing officer. Provider concerns escalate from the resident or the ordering provider to the attending physician, to the department chief, and to the medical director, with risk management and the ethics committee available as parallel resources.

'''Rules for using it:''' address the concern with the person involved first when it is safe to do so, escalate one level at a time, escalate promptly rather than at the end of the shift, document each step, and '''never carry out an order the nurse believes is unsafe or incorrect'''. A nurse who follows a wrong order shares liability with the person who wrote it. The correct action is to clarify with the ordering provider and, if unresolved, escalate.

== Ethical Principles ==

Ethics addresses what ought to be done when values conflict; law addresses what must be done. An action can be legal and unethical, or ethical and illegal.

* '''Autonomy:''' the right of a competent person to self-determination. Underpins informed consent, refusal of treatment, and advance directives.
* '''Beneficence:''' acting for the patient's good.
* '''Nonmaleficence:''' avoiding harm. "First, do no harm."
* '''Justice:''' fairness in the distribution of care and resources; treating like cases alike.
* '''Fidelity:''' keeping commitments and being faithful to the patient and the profession.
* '''Veracity:''' truthfulness.
* '''Accountability and responsibility:''' answering for one's own actions and accepting the obligations of the role.

'''Advocacy''' is the applied form of these principles: informing patients of their rights, supporting their decisions even when the nurse disagrees, and speaking for those who cannot speak for themselves. A recurring examination pattern is that supporting the patient's own informed choice is more often correct than persuading the patient toward the clinically preferred option.

'''Moral distress''' occurs when the nurse knows the ethically right action but is constrained from taking it. It is a recognized contributor to burnout and turnover, and the constructive responses are to name it, use the chain of command, and request an '''ethics committee''' consultation. Ethics committees provide education, policy guidance, and non-binding case consultation; they advise, they do not decide for the patient.

The '''ANA Code of Ethics for Nurses''' is the profession's own statement of its obligations and is non-negotiable, though it is not itself law (ANA, 2015).

== Client Rights ==

Patients retain the rights to: considerate and respectful care; information about diagnosis, treatment, and prognosis in understandable terms; participation in decisions about their care; refusal of treatment and of participation in research; an advance directive that will be honored; privacy and confidentiality; access to and a copy of their own medical record; an explanation of charges; knowledge of facility policies affecting care; freedom from restraint or seclusion used for staff convenience, coercion, discipline, or retaliation; freedom from abuse, neglect, and exploitation; interpreter services; and the ability to voice a grievance without retaliation.

'''Application note.''' Patients also have the right to leave '''against medical advice'''. A competent adult who wishes to leave is informed of the risks, asked to sign the AMA form, and offered follow-up and prescriptions; the provider is notified. Refusing to sign the form does not authorize detaining the patient. Physically preventing a competent adult from leaving is false imprisonment.

== Performance Improvement and Safety Systems ==

Quality improvement is a continuous, data-driven, systems-focused process rather than an exercise in assigning individual blame. Nurses participate by collecting data, auditing charts, serving on committees, and reporting events.

* '''Plan-Do-Study-Act (PDSA)''' is the most commonly tested improvement cycle: plan a small change, do it on a small scale, study the results, and act by adopting, adapting, or abandoning it.
* '''Sentinel event:''' a patient safety event that reaches the patient and results in death, permanent harm, or severe temporary harm. It requires immediate investigation and response.
* '''Root cause analysis''' is a retrospective, systems-level analysis performed '''after''' an event to find why it happened and what process change will prevent recurrence. '''Failure mode and effects analysis''' is the '''prospective''' counterpart, performed before an event to identify where a process could fail.
* '''Never events''' are serious, largely preventable occurrences such as wrong-site surgery or a retained foreign object; several are not reimbursed by payers.
* '''Structure, process, and outcome''' is the classic framework for what to measure: how care is organized, what is done, and what resulted.
* '''Nurse-sensitive indicators''' are outcomes strongly influenced by nursing care, including pressure injuries, falls with injury, catheter-associated urinary tract infections, and central line-associated bloodstream infections.
* '''Just culture''' distinguishes human error, at-risk behavior, and reckless behavior, and responds with consoling, coaching, or discipline respectively. It supports reporting rather than punishing it.

== Interdisciplinary Collaboration ==

Effective teams share a mental model of the plan, communicate in a structured way, and have an explicit mechanism for any team member to stop the line when something is unsafe. The RN is most often the coordinator, because the RN is present continuously and holds the whole picture.

Common team members and what they contribute include the provider (diagnosis and orders), the pharmacist (drug interactions, dosing, reconciliation), the registered dietitian (nutrition and diet texture), physical therapy (mobility, strength, gait, and assistive devices), occupational therapy (activities of daily living and adaptive equipment), speech-language pathology (swallowing and communication), respiratory therapy (airway and ventilation), the social worker (psychosocial, financial, and placement resources), the case manager (coordination and utilization), the chaplain (spiritual care), and the wound, ostomy, and continence nurse.

'''Application note.''' A large family of examination items is answered simply by matching a patient need to the correct discipline. A patient who coughs while drinking thin liquids needs speech-language pathology, not a thickened-liquid order the nurse writes independently. A patient who cannot afford medications needs the social worker or case manager, not a lecture on adherence.

== Information Technology ==

Nurses are accountable for the security and integrity of electronic records. Core rules: never share a password or badge; log off before leaving a workstation; access only records for patients in one's care; use secure, approved channels for clinical communication; and report any suspected breach immediately. Clinical decision support alerts should be evaluated rather than reflexively dismissed, and repeated overrides are themselves a quality signal. Barcode medication administration is scanned at the bedside, not in advance, and a scan failure is investigated rather than bypassed. Downtime procedures require documentation on paper forms and later reconciliation into the record.

== High-Yield Summary ==

* Accountability for a delegated task always stays with the delegating nurse.
* Never delegate '''assessment, teaching, evaluation, or judgment''', and never delegate an '''unstable''' patient.
* Assistive personnel do standard, unvarying tasks on stable patients and report data; they do not interpret it.
* The LPN collects data, reinforces teaching, and cares for stable patients with predictable outcomes.
* Prioritize by ABC, then unstable over stable, then acute over chronic, then actual over potential, then Maslow.
* Assess before intervening, except in an immediate life threat with an obvious fix.
* In a disaster, the goal shifts to the greatest good for the greatest number.
* The provider obtains informed consent; the nurse witnesses the signature and verifies understanding, and stops the process if the patient is confused.
* A DNR order limits resuscitation only; all other indicated care continues.
* An advance directive applies only after the patient loses capacity, and the competent patient's current wish always governs.
* Malpractice requires duty, breach, causation, and damages, all four.
* Restraints require a time-limited order, are never PRN, are tied to the movable bed frame with a quick-release knot, and are the least restrictive option that works.
* Do not chart in the medical record that an incident report was filed.
* Never carry out an order believed to be unsafe; clarify, then escalate through the chain of command.

== References ==

American Nurses Association. (2015). ''Code of ethics for nurses with interpretive statements''. Nursesbooks.org.

Centers for Medicare & Medicaid Services. (2020). ''State operations manual, appendix A: Survey protocol, regulations and interpretive guidelines for hospitals''. U.S. Department of Health and Human Services.

Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. ''Joint Commission Journal on Quality and Patient Safety, 32''(3), 167-175. https://doi.org/10.1016/S1553-7250(06)32022-3

Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1936 (1996).

National Council of State Boards of Nursing. (2026a). ''2026 NCLEX-RN test plan: Test plan for the National Council Licensure Examination for registered nurses'' (effective April 2026). NCSBN. https://www.ncsbn.org

National Council of State Boards of Nursing. (2026b). ''2026 NCLEX-PN test plan: Test plan for the National Council Licensure Examination for practical nurses'' (effective April 2026). NCSBN. https://www.ncsbn.org

National Council of State Boards of Nursing & American Nurses Association. (2019). ''National guidelines for nursing delegation''. NCSBN.

Patient Self-Determination Act of 1990, Pub. L. No. 101-508, §§ 4206, 4751, 104 Stat. 1388 (1990).

The Joint Commission. (2017). ''Sentinel event alert 58: Inadequate hand-off communication''. The Joint Commission.

[[Category:Management of Care]]
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